The Senate is in the very middle of making sausage. Many progressives are distressed at the loss of a robust public option. Many fiscal conservatives are disheartened that the bill does not do more to control costs. But having seen this movie before, I know that the only thing worse than a distressing bill is a needed and good bill that goes unpassed.

The Senate is engaging in tortuous compromise with a practical goal: 60 votes. Many of the compromises taking place are bipartisan, innovative and cost-effective. Some are not. But the main thing is ensuring access to insurance for tens of millions of citizens who need it. Exactly how we get there is more or less a detail.

I believe in bipartisanship (even though now it feels a bit like believing in the tooth fairy), because I believe that is how you reach most Americans. A bill that tries to appeal across party lines and that a broad range of Americans will embrace no doubt fits my definition of a "better" bill. But an important and good bill that can actually pass more than meets my criteria of legislation that should move forward, and I believe the Senate will do precisely that in the days ahead.

DOUGLAS E. SCHOEN

Democratic pollster and author

The Senate health-care bill appears to be improving, if only because the so-called public option appears, for the time being, to be dead.

Until recently, the public option was the main stumbling block to reaching an agreement. With the apparent willingness of liberals and moderate Democrats to agree to drop any formal role for the government in administering a government-run health insurance scheme, a major step forward seemingly has been taken. Further, with House Speaker Nancy Pelosi indicating, however tentatively, that she believes agreement can be reached in a conference committee to reconcile the House and Senate proposals, we now have the first indication that this will not ultimately be a deal-breaker. The importance of this cannot be overstated.

This is not the end of the story. In the place of the public option, a number of possible deal-breakers have emerged, including the new plan to allow 55-to-64-year-olds to buy into Medicare, as well as the issues of abortion funding, drug importation and immigration.

In the end, everything hinges on the Congressional Budget Office's forthcoming score of the new Democratic proposal. If the price tag comes in at under $1 trillion, and ideally under $900 billion, offering some amount of deficit reduction in future years, the new plan will be seen as a huge step forward.

And if the new proposal is ultimately seen as too expensive and offering little in the way of deficit reduction, the Democrats will most likely be back to square one.

MICHAEL O. LEAVITT

Secretary of health and human services, 2005-09

For four successive years as a trustee of the Medicare trust fund, I listened to reports from the government actuary of the system's impending insolvency. When the next report comes out in the spring, I predict, based on recent economic conditions, an announcement that Medicare is within a presidential term of bankruptcy. The Senate proposal to add millions of people to Medicare will accelerate the program's collapse.

Premiums for 55- to 64-year-olds would be high. Mostly the sick will apply. Separate provisions of the bill ensure that others can buy insurance after they get sick. In a short time, Congress will succumb to pressure to subsidize the premiums with tax dollars.

The representation that only a narrow group would be eligible is an illusion. The program will quickly experience the same eligibility creep every other government health insurance program has experienced.

Expanding Medicare will hurt hospitals, drive doctors from participating in Medicare and drive up the budget deficit. Medicare's fatally flawed fee-for-service system underlies the ruinous path we are on. Congress should fundamentally restructure Medicare rather than blindly add to its task.

ED ROGERS

White House staffer to Ronald Reagan and George H.W. Bush; chairman of BGR Group

The Democratic ideas for Americans' health care have gone from a ridiculous over-reach of government control in the House to just ridiculous in the Senate.

It appears that there was a meeting in the Senate majority leader's office, and the question under consideration changed from "how do we reform health care?" to "how do we drive up health-care costs and diminish health-care quality for the greatest number of people?" Answer: "Well, we could radically increase participation in the struggling Medicare system." Someone said "Great idea!" and Harry Reid was out the door and in front of the cameras announcing this plan, which no one has dared to propose in years for fear of ridicule.

The saddest part is that some real bipartisan reform is still possible. If Reid would abandon the Christmas deadline, lock himself in a room with Sens. John McCain (R-Ariz.), Richard Burr (R-N.C.) and a few others, a real bipartisan consensus would emerge.

AL FROM

Founder of the Democratic Leadership Council; principal of The From Co.

Real health-care reform requires that good intentions be accompanied by tough actions. The potential compromise in the Senate seems heavier on the former than the latter. As a result, it's likely to fall short of President Obama's objectives of expanding coverage, lowering costs and improving quality -- without adding to the federal deficit.

Replacing the public option with a plan modeled after the Federal Employees Health Plan -- an exchange offering a choice of private insurance plans -- is a positive step. But allowing 55- to 64-year-olds to buy into Medicare undercuts that by expanding a costly public plan that is fast going broke. Doing so could also shift costs to the privately insured because Medicare pays providers less than private insurance.

To subsidize insurance for the uninsured and cover people who have preexisting conditions without breaking the bank, such a plan needs to include a strong mandate that requires everyone to buy insurance; incentives to replace fee-for-service payments with more efficient models; fees on "Cadillac plans"; and limits on abuses in malpractice suits.

That's why, contrary to conventional wisdom, the president's best allies are the centrist Democratic senators insisting on an honest plan that jettisons the public option and contains such reforms. They should continue to stand firm -- even if it means the Senate does not finish health reform this year.

LEN NICHOLS

Director of New America Foundation's Health Policy Program; senior adviser for health policy in the Office of Management and Budget, 1993-94

The Senate bill is getting better in three ways:

First, a large group of freshman senators introduced package of amendments that enhance the Senate legislation's ability to control costs and improve quality. They (1) ensure that all providers will be rewarded for value, not volume; (2) broaden the scope of an Independent Advisory Board to include recommendations for the whole health-care system; and (3) call for the immediate review and timely removal of legal and regulatory barriers to new payment models that would improve quality and efficiency of all physicians, hospitals and payers.

Finally, a team of 10 Democratic senators with diverse perspectives is working on the last details of a package that includes the long-awaited public-option denouement. These leaders are creating consensus and balance among the compelling goals of expanding consumer choice, intensifying insurer competition, and maintaining access to high-quality providers for current and future Medicare beneficiaries. This bill is moving in the right direction, toward the right outcome: law.

KARL ROVE

White House deputy chief of staff and senior adviser to George W. Bush; columnist for Newsweek and the Wall Street Journal; Fox News contributor

The sketchy outline of Sen. Harry Reid's latest "deal" is progress all right, but only for those who want a single-payer system, full-speed ahead and damn the fiscal torpedoes.

Opening Medicare to everyone ages 55 to 64 is expanding government-run health care. Government sets the payment rates. This price-fixing means hospitals and doctors get paid much less than they would be paid by insurance companies. Government decides whether patient claims are allowed: Medicare's refusal rate is twice the average of insurance companies.

And does it really make sense to expand a Medicare program that's already going to be broke by 2017, when its revenue is projected to be less than its annual outlays?

The Reid bill does expand coverage by roughly 31 million people, but 15 million of them get coverage by being dropped into Medicaid, which is second-class health care and is already busting most state governments' budgets.

New numbers from the Joint Committee on Taxation show 11 percent of middle-class Americans will be better off through a combination of subsidies and tax changes, but 41 percent will be worse off, suffering premium and tax increases. No wonder public opinion continues swinging against proposals being shoved through Congress.

TERRY O'NEILL

President, National Organization for Women

The health-care reform being assembled in the Senate is a crazy quilt of ideas. Some are good, but others endanger the health of women -- and since negotiations are ongoing, it might get decidedly worse if the wrong deals are struck.

On the plus side is the amendment sponsored by Sen. Barbara Mikulski (D-Md.) guaranteeing mammogram coverage for women. Also, the expansion of Medicare will greatly assist women ages 55 to 64. But the Senate hasn't eliminated age-rating by insurance companies, which will force middle-aged women to pay sky-high rates.

Even worse, the attempt to eliminate coverage of abortion care did not truly end with the defeat of the highly restrictive Nelson amendment. There must be no backroom deals designed to lure Sen. Ben Nelson (D-Neb.) and others back into the fold by including any elements of the amendments that abortion foes such as Nelson favor.

There also must be no deals to drop the public option. This is the only way the government can negotiate rates with insurance companies and keep costs under control. Further, if states wish to pursue their own public or single-payer options, they must be allowed to do so.

If health reform is to pass, it should not trade off the rights and needs of some women to benefit others. If the health reform bill codifies a history-making rollback of abortion rights, it is not real reform.